KOMA Annual Conference June 26, 2015 Boyd R. Buser, D.O., FACOFP

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1 KOMA Annual Conference June 26, 2015 Boyd R. Buser, D.O., FACOFP

2 Today s Presentation Intro to TCM codes CPT 2014 Editorial Revisions External Documentation Resources Overview of Chronic Care Management and Complex Chronic Care Coordination (CCCC) Codes Q&A

3 Chronic Care Coordination Workgroup July 19 Proposed Rule for 2012 Medicare Physician Payment Schedule CMS requested that RUC review all of E/M to ensure that care coordination was appropriately valued July 29, 2011 Meeting with Donald Berwick, MD (CMS Administrator) Doctors Robert Wah (AMA Board Trustee), Peter Hollmann (Chair of CPT) and Barbara Levy (Chair of RUC)

4 Chronic Care Coordination Workgroup Specialty society comments to CMS and AMA s message was consistent: a re-review of E/M would not be productive and would not address CMS stated goals: Incentivize care coordination and improve health care delivery to patients with chronic disease Improve payments to primary care to shore up primary care and nursing

5 Chronic Care Coordination Workgroup Informed Doctor Berwick that the CPT Editorial Panel and the RUC would engage in an effort to ensure that the coding and valuation of care coordination are appropriate. Created the Chronic Care Coordination Workgroup (C3W) in August David Hitzeman, DO (AOA RUC delegate) was a member of the workgroup

6 Chronic Care Coordination Workgroup The charge to the C3W was to provide strategic direction to CPT and RUC to address the adequacy of coding and valuation of care coordination services and prevention/ management of chronic disease. A request to CMS to immediately implement payment for anticoagulant management, telephone calls, team conferences and patient education was submitted to CMS on October 3, CMS declined to implement this recommendation.

7 Chronic Care Coordination Workgroup In Fall 2011, the C3W recommended that codes for transitional care management and complex chronic care management be developed for CPT CPT Editorial Panel completed this work in May 2012 (CPT workgroup co-chaired by 2 DOs and 1 MD Family Physician). Codes and for Transitional Care Management (TCM) were added to the CPT code set in Codes 99487, and for Complex Chronic Care Coordination (CCCC) were also added to CPT 2013

8 Transitional Care Management Services (TCM) The transition in care is from: an inpatient hospital setting partial hospital (psych) observation status in a hospital skilled nursing facility/nursing facility To the patient s community setting: home domiciliary rest home or assisted living 8

9 Transitional Care Management Services (TCM) Codes 99495, 99496: Are reported once per patient within 30 days of discharge Are selected based on medical decision making and the date of the first face-to-face visit May only be reported by one individual 9

10 Transitional Care Management Services (TCM) Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit, within 14 calendar days of discharge 10

11 Transitional Care Management Services (TCM) Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of high complexity during the service period Face-to-face visit, within 7 calendar days of discharge 11

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13 Transitional Care Management Services (TCM) Regarding the required face-to-face visit, CPT states: The first face-to-face visit is part of the TCM service and not reported separately. Additional E/M services provided on subsequent dates after the first face-to-face visit may be reported separately.

14 Transitional Care Management Services Editorial Revisions Expanded applicability to new patients Transitional Care Management Services Codes and are used to report transitional care management services (TCM). These services are for a new or established patient whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care from an inpatient hospital setting 14

15 Transitional Care Management Services Editorial Revisions Clarify separately reported E/M services should be provided on subsequent dates TCM requires a face-to-face visit, initial patient contact,and medication reconciliation within specified time frames. The first face-to-face visit is part of the TCM service and not reported separately. Additional E/M services provided on subsequent dates after the first face-to-face visit may be reported separately. TCM requires an interactive contact with the patient or caregiver 15

16 Transitional Care Management Services Editorial Revisions Specify the discharge services may not constitute the required face-to-face visit Only one individual may report these services and only once per patient within 30 days of discharge. Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within the 30 days. The same individual may report hospital or observation discharge services and TCM. However, the discharge service may not constitute the required face-to-face visit. The same 16

17 Transitional Care Management Services 2014 Editorial Revisions Clarify the same individual should not report TCM during the postop period the individual reported. Only one individual may report these services and only once per patient However, the discharge service may not constitute the required face-to-face visit. The same individual should not report TCM services provided in the postoperative period of a service that the individual reported. 17

18 Transitional Care Management Services (TCM) Q: TCM codes require interactive contact within two business days. What if I can t reach the patient or caregiver within this time frame? A: Refer to the Transitional Care Management Coding Tip in the CPT code set.. 18

19 Transitional Care Management Services (CPT 2014, page 49) Coding Tip The required contact with the patient or caregiver, as appropriate, may be by the physician or qualified health care professional or clinical staff. Within two business days of discharge is Monday through Friday except holidays without respect to normal practice hours or date of notification of discharge. The contact must include capacity for prompt interactive communication addressing patient status and needs beyond scheduling follow-up care. If two or more separate attempts are made in a timely manner, but are unsuccessful and other transitional care management criteria are met, the service may be reported. 19

20 Transitional Care Management Services (TCM) Transitional Care Management Forms can be used to track the TCM Services. Examples: American Academy of Family Physicians American College of Physicians 20

21 Transitional Care Management Services (TCM) Other Resources Frequently Asked Questions about Billing Medicare for Transitional Care Management Services Service-Payment/PhysicianFeeSched/Downloads/FAQ- TCMS.pdf 21

22 Complex Chronic Care Coordination Services (CCCC) Complex chronic care coordination services are patient centered management and support services provided by physicians, other qualified health care professionals, and clinical staff to an individual who resides at home or in a domiciliary, rest home, or assisted living facility. These services typically involve clinical staff developing, substantially revising, and implementing a care plan under direction of the physician or other qualified health care professional.

23 Complex Chronic Care Coordination Services (CCCC) Patients who require complex chronic care coordination services may be identified by practice-specific or other published algorithms that recognize multiple illnesses, multiple medication use, inability to perform activities of daily living, requirement for a caregiver, and/or repeat admissions or emergency department visits. Typical adult patients take or receive three or more prescription medications and may also be receiving other types of therapeutic interventions (eg, physical therapy, occupational therapy) and have two or more chronic continuous or episodic health conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Typical pediatric patients receive three or more therapeutic interventions (eg, medications, nutritional support, respiratory therapy) and have two or more chronic continuous or episodic health conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

24 The care coordination office/practice must have the following capabilities: Provide 24/7 access to physicians or other qualified health care professionals or clinical staff; Use a standardized methodology to identify patients who require chronic complex care coordination services; Have an internal care coordination process/function whereby a patient identified as meeting the requirements for these services starts receiving them in a timely manner; Use a form and format in the medical record that is standardized within the practice; Be able to engage and educate patients and caregivers as well as coordinate care among all service professionals, as appropriate for each patient.

25 Complex Chronic Care Coordination Services (CCCC) Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with no face-to-face visit, per calendar month first hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month (deleted) each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure) (Report in conjunction with 99487, 99488)

26 Complex Chronic Care Coordination Services (CCCC) The CCCC codes include care plan oversight services (99339, 99340, ), prolonged services without direct patient contact (99358, 99359), anticoagulant management (99363, 99364), medical team conferences ( ), education and training ( , 99071, 99078), telephone services ( , ), on-line medical evaluation (98969, 99444), preparation of special reports (99080), analysis of data (99090, 99091), transitional care management services (99495, 99496), medication therapy management services ( ) and, if performed, these services may not be reported separately during the month for which are reported.

27 Complex Chronic Care Coordination Services (CCCC) Codes 99487, and for Complex Chronic Care Coordination (CCCC) were added to CPT 2013 The codes went through the RUC survey process and RVUs were recommended to CMS CMS declined to pay for the codes in 2013 Some private payers (e.g., Aetna) have covered these codes since their introduction The CPT Editorial Panel made a number of clarifying editorial changes to the codes, which appear in CPT 2014 CMS will pay for these services in CY2015

28 Chronic Care Management Services CMS created G code for reporting these services Expands the number of eligible patients CPT created a code that mirrors the CMS G code (99490) Went through the RUC process for development of RVU recommendations

29 Questions?